Periodontal Disease
and Endocrinology/Diabetology

by Shailesh B. Patel, BM, ChB, DPhil, FRCP

The art and science of medicine has a long and rich history. A new concept highlighted and championed can alter the practice of medicine. For over 1,000 years, such ideas have frequently led to practice changes. What is new and modern is the rigor with which we view these innovative concepts. Evidence-based medicine is now the standard. However, rounds or teaching sessions are too often stifled by cries of “There are no clinical trials”, or “Where is the evidence”? In the absence of clinical data, these excuses should not temper “judgment-based practice”.

Shailesh B. Patel, BM, ChB, DPhil, FRCP, Professor and Chief, Division of Endocrinology, Metabolism, and Clinical Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin

“Judgment-based practice” relies on established basic and clinical scientific principles, on experience
(personal and collective), and on using procedures or therapies that have been shown to be effective, pose
no untoward risk (do no harm), and may prove beneficial (a positive risk-benefit ratio).

The Scottsdale Project brought together a group of professionals from all branches of healthcare to highlight an important and neglected area: the constellation of periodontitis, diabetes, and adverse outcomes. The link between dental health, oral flora, and systemic illness is well known, e.g., in subacute bacterial endocarditis. Enlightened cardiothoracic surgeons now ask their patients before undergoing elective cardiac surgery to receive clearance from their dentists (as this improves patient morbidity and mortality), above and beyond valvular procedures. Purulence anywhere in the body needs to be treated and the mouth is no different. Judgment-based practice would dictate that treating purulence in the mouths of diabetic patients is something good.

Periodontitis can be readily screened, treated and controlled, but we are not doing it. Good management of any patient with a chronic disease demands a holistic approach; treating not just the organ, but the body, the mind and even the soul. There are many reasons why we as clinicians fail to be holistic. Finding the time to take a good clinical history, perform a thorough physical exam, adequately answer our patients’ questions and then meet extensive practice guidelines is challenging.

For diabetic patients, annual eye, foot, lipid, and urine protein exams are documented routinely. How-
ever, we do not examine the diabetic patient’s mouth systematically or document if they have had their
annual dental exam. This highlights the difference between evidence-based medicine and judgment-based
practice.

In the systematic review of the literature considered for The Scottsdale Project, a wealth of evidence shows that periodontitis is a significant comorbidity in patients with diabetes. Yes, we still need more studies for evidence-based medicine. However, the lack of these trials should not derail judgment-based practice. I would urge the American Diabetes Association and the American College of Clinical Endocrinologists to consider, at a minimum, a “judgment-based” statement that an annual dental exam for gum and periodontal health in all diabetic patients is required.

However, another aspect of this problem may be more difficult to solve. In clinical medicine, whether
a patient has insurance or not, chronic illnesses can usually be managed, as there are both state and federal
resources to help provide care, despite struggles.

Unfortunately, there are few resources for dental coverage in the state and federal systems (even the Veterans Administration does not provide for dental coverage). With already burdensome medical costs, to pay out-of-pocket to receive a dental exam is unaffordable for those that are at the greatest risk. Despite sound judgment, the oral-systemic connection between health and disease remains lost to our healthcare insurers and our politicians. Periodontitis, the inflammation of the gums, is part of medicine and as such should be part of medical healthcare.